Therapeutic Combination and Methods of Treatment With a DLL4 Antagonist and an Anti-Hypertensive Agent

ABSTRACT

Methods for treating cancer comprising administering a DLL4 antagonist and one or more anti-hypertensive agents are described. Also described are pharmaceutical compositions comprising a DLL4 antagonist and one or more anti-hypertensive agents, and kits comprising the same.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the priority benefit of U.S. ProvisionalApplication No. 61/252,473, filed Oct. 16, 2009 which is herebyincorporated by reference herein in its entirety.

DESCRIPTION OF THE INVENTION

1. Field of Invention

The present invention relates to the field of oncology and providesnovel compositions and methods for treating cancer. The presentinvention provides a pharmaceutical composition comprising a DLL4antagonist and one or more anti-hypertensive agents, and methods andkits for using the same.

2. Background

Cancer is one of the leading causes of death in the developed world,with over one million people diagnosed with cancer and 500,000 deathsper year in the United States alone. Overall it is estimated that morethan 1 in 3 people will develop some form of cancer during theirlifetime. There are more than 200 different types of cancer, four ofwhich—breast, lung, colorectal, and prostate—account for over half ofall new cases (Jemal et al., 2003, Cancer J. Clin. 53:5-26).

Increasingly, treatment of cancer has moved from the use of systemicallyacting cytotoxic drugs to include more targeted therapies that hone inon the mechanisms that allow unregulated cell growth and survival. Tumorangiogenesis, the process by which a tumor establishes an independentblood supply, is a critical step for tumor growth. Efforts to targettumor angiogenesis have emerged as an important strategy for thedevelopment of novel cancer therapeutics.

Tumors cannot continue to grow beyond about 2 mm in diameter withoutdeveloping blood vessels to deliver oxygen and nutrients, and to removecellular waste. Tumors release angiogenic factors that act on thereceptors of endothelial cells of nearby blood vessels, causingproliferation and the development of new blood vessels directed towardthe site of angiogenic factor release, i.e., the tumor. Thistumor-induced vasculature has received enormous interest as a target forantineoplastic therapy because a relatively small number of bloodvessels are critical for the survival and continued growth of a muchlarger group of cancer cells. The disruption in the function of a singletumor blood vessel can result in an avalanche of ischemic cell death andnecrosis of thousands of tumor cells which depend on it for bloodsupply. Thus, drugs that disrupt the ability of a tumor to induce ormaintain an independent blood supply are promising cancer treatments.

Drugs that target tumor angiogenesis generally fall into one of twocategories: anti-angiogenic drugs and dysangiogenic drugs.Anti-angiogenic drugs block the development and maintenance of new bloodvessels, and thus impede tumor growth. An example of an anti-angiogenicdrug is bevacizumab (Avastin®), an anti-vascular endothelial growthfactor (VEGF) antibody. Dysangiogenic drugs, in contrast, result indisregulated angiogenesis, leading to the development of dysfunctionalor nonfunctional vasculature.

The Notch pathway is involved in multiple aspects of vasculardevelopment including proliferation, migration, smooth muscledifferentiation, angiogenesis and arterial-venous differentiation (Isoet al., 2003, Arterioscler. Thromb. Vase. Biol. 23:543). The Notchreceptor ligand DLL4 (Delta-like ligand 4) is an important component ofthe Notch pathway and plays a role in angiogenesis. Heterozygous loss ofDLL4 result in severe defects in arterial development and yolk sacvascularization, leading to embryonic lethality. (Duarte et al., 2004,Genes Dev., 18:2474-78; Gale et al., 2004, PNAS, 101:15949-54; Krebs etal., 2004, Genes Dev., 18:2469-73) Furthermore, tumor cells and tumorvasculature over express DLL4, suggesting that DLL4 expression is animportant player in tumor angiogenesis. (Patel et al., 2005, CancerRes., 65:8690-97; Yan et al., 2001, Blood, 98:3793-99) Thus, blockingDLL4 signaling has emerged as a promising avenue for the development ofnew anti-cancer therapies.

Blocking DLL4 signaling, such as by an anti-DLL4 antibody, has beenshown to reduce tumor growth by multiple different mechanisms. (Ridgwayet al., 2006, Nature, 444:1083-87; Noguera-Troise et al., Nature,444:1032-37; Hoey et al., 2009, Cell Stem Cell, 5:168-77) For example,DLL4 blocking antibodies have been reported to result in endothelialcell proliferation and the development of blood vessels, however, theseblood vessels lack a functional lumen. This dysangiogenic effect hasbeen reported to block tumor growth by promoting the development of onlynon-functional blood vessels. (Ridgeway et al. and Noguera-Troise et al.(above); Scehnet et al., 2007, Blood, 109:4753-60) Additionally, DLL4blocking antibodies have been shown to inhibit tumor growth by reducingthe proliferation of tumor cells and reducing cancer stem cellfrequency. Although the mechanism behind the reduction of tumorinitiating cells (cancer stem cells, or CSCs) is unknown, it ishypothesized that DLL4 is required for the self-renewal of CSCs andmaintains these cells in an undifferentiated state. (Hoey et al., above)

Unlike therapeutic approaches that attempt to block the signaling oftumor angiogenic factors, blockade of DLL4 signaling by anti-human DLL4antibodies can result in endothelial hypertrophy and the creation ofnon-functional microvessels. Consequently, even in the presence of tumorangiogenic factors, blockade of DLL4 signaling, through administrationof anti-human DLL4 antibodies, can result in dysangiogenesis whichinhibits the ability of the tumor to induce the functional blood vesselformation needed to support growth of the tumor.

Anti-angiogenic drugs, such as the anti-VEGF antibody bevacizumab(Avastin®), sunitinib (Sutent®), and sorafenib (Nexavar®), are known tocause hypertension in about one-third of patients who take them.Although anti-Dll4 antibodies have been reported to inhibit tumorangiogenesis by promoting dysangiogenesis, a mechanism different thanthat of traditional anti-angiogenic treatments, the present inventorshave now surprisingly found that an anti-Dll4 antibody can causehypertension in some patients. Thus, there is a need for methods oftreating cancer with a DLL4 antagonist, such as an anti-DLL4 antibody,while controlling the hypertension caused thereby.

It is a purpose of the invention to provide pharmaceutical compositions,methods, and kits for treating cancer with a DLL4 antagonist whilecontrolling hypertension through the administration of one or moreanti-hypertensive agents.

SUMMARY OF THE INVENTION

Provided are methods for treating cancer comprising administering to asubject in need thereof a DLL4 antagonist and one or moreanti-hypertensive agents. Further provided are compositions and kitscomprising a DLL4 antagonist and one or more anti-hypertensive agents.Also provided are methods of ameliorating hypertension in a patientreceiving treatment with a DLL4 antagonist comprising administering tothe patient an effective amount of one or more anti-hypertensive agents.Further provided are methods of preventing hypertension in a patientreceiving treatment with a DLL4 antagonist comprising administering tothe patient an effective amount of an anti-hypertensive agent. Alsoprovided are methods of monitoring a patient receiving treatment with aDLL4 antagonist for the development of hypertension, comprisingmeasuring the blood pressure of a patient receiving treatment with aDLL4 antagonist and administering to the patient with a blood pressureabove normal range one or more anti-hypertensive agents.

In certain embodiments, the DLL4 antagonist is an antibody thatspecifically binds DLL4 (i.e., an anti-DLL4 antibody). In certainembodiments, the DLL4 to which the anti-DLL4 antibody binds is humanDLL4. In one embodiment, the anti-DLL4 antibody is a monoclonalantibody. In a further embodiment, the anti-DLL4 antibody specificallybinds to a human DLL4 epitope comprising amino acids within the humanDLL4 N-terminal region comprising SEQ ID NO: 11. In other embodiments,the anti-DLL4 antibody is a humanized antibody or a human antibody. In afurther embodiment, the humanized anti-DLL4 antibody is encoded by theplasmid deposited with ATCC on May 10, 2007, having ATCC deposit numberPTA-8425, also known as 21M18 H7L2 and OMP-21M18. In a furtherembodiment, the humanized anti-DLL4 antibody is encoded by the plasmiddeposited with ATCC on May 10, 2007, having ATCC deposit numberPTA-8427, also known as 21M18 H9L2. In yet another embodiment, theanti-DLL4 antibody competes with the antibody OMP-21M18 for binding toDLL4.

In certain embodiments, the anti-hypertensive agent is selected from thegroup consisting of: diuretics, adrenergic receptor antagonists,adrenergic receptor agonists, calcium channel blockers, ACE inhibitors,angiotensin II receptor antagonists, aldosterone antagonists,vasodilators, renin inhibitors, and combinations thereof.

Administration of the DLL4 antagonist and one or more anti-hypertensiveagents can be simultaneous or sequential. When administeredsequentially, either the DLL4 antagonist or the anti-hypertensive agentcan be administered first. In certain embodiments, administration of theDLL4 antagonist and anti-hypertensive agent is chronic; that is, thesubject receiving treatment will be given multiple doses of the DLL4antagonist and the anti-hypertensive agent over an extended period oftime.

The subject in need of treatment suffers from cancer and can eithersuffer from hypertension, be at risk for developing hypertension, or isa subject in which the prevention or inhibition of hypertension isdesirable. In certain embodiments, the subject in need of treatment isat risk for cardiovascular disease. In other embodiments, the subject inneed of treatment cannot otherwise be treated with an appropriate,effective dose of a DLL4 antagonist without developing hypertension. Inother embodiments, the subject does not have a prior history ofhypertension and/or cardiovascular disease.

The invention also provides kits comprising a container, wherein thecontainer contains therein a pharmaceutical composition comprising aDLL4 antagonist and a pharmaceutically acceptable carrier, and whereinthe container further comprises a package insert indicating that thecomposition can be used in combination with one or moreanti-hypertensive agents. In certain embodiments, the kit comprises ananti-DLL4 antibody and a package insert contained within a container. Inother embodiments, the kit comprises an anti-DLL4 antibody, at least oneanti-hypertensive agent, and a package insert contained within acontainer.

Additional objects and advantages of the invention will be set forth inpart in the description which follows, and in part will be obvious fromthe description, or can be learned by practice of the invention. Theobjects and advantages of the invention will be realized and attained bymeans of the elements and combinations particularly pointed out in theappended claims. It is to be understood that both the foregoing generaldescription and the following detailed description are exemplary andexplanatory only and are not restrictive of the invention, as claimed.In the specification and the appended claims, the singular forms “a,”“an,” and “the” include plural reference unless the context clearlydictates otherwise.

DESCRIPTION OF THE FIGURES

FIG. 1: The Table of FIG. 1 is a summary of the blood pressure readingsand anti-hypertensive treatments of Subject 1, a 78-year-old male withadenocarcinoma of the caecum with metastases to the liver, throughout aPhase I clinical trial of OMP-21M18. Subject 1 was enrolled in the 0.5mg/kg OMP-21M18 cohort.

FIG. 2: The Table of FIG. 2 is a summary of the blood pressure readingsand anti-hypertensive treatments of Subject 2, a 55-year-old male withlow-grade leiomyosarcoma, throughout a Phase I clinical trial ofOMP-21M18. Subject 2 was enrolled in the 1.0 mg/kg OMP-21M18 cohort.

FIG. 3: The Table of FIG. 3 is a summary of the blood pressure readingsand anti-hypertensive treatments of Subject 3, a 64-year-old woman witha choroidal melanoma of the right eye and metastases in both the liverand the lung, throughout a Phase I clinical trial of OMP-21M18. Subject3 was enrolled in the 2.5 mg/kg OMP-21M18 cohort.

FIG. 4: The Table of FIG. 4 is a summary of the blood pressure readingsand anti-hypertensive treatments of Subject 5, a 56-year-old female withstage IV colorectal cancer, throughout a Phase I clinical trial ofOMP-21M18. Subject 5 was enrolled in the 10 mg/kg OMP-21M18 cohort.

FIG. 5: The Table of FIG. 5 is a summary of the blood pressure readingsand anti-hypertensive treatments of Subject 7, a 71-year-old female withstage IV adenocarcinoma of the rectosigmoid junction, throughout a PhaseI clinical trial of OMP-21M18. Subject 7 was enrolled in the 10 mg/kgOMP-21M18 cohort.

FIG. 6: The Table of FIG. 6 is a summary of the blood pressure readingsand anti-hypertensive treatments of Subject 8, a 58-year-old man withstage IV colorectal cancer, throughout a Phase I clinical trial ofOMP-21M18. Subject 8 was enrolled in the 10 mg/kg OMP-21M18 cohort.

FIG. 7: The Table of FIG. 7 is a summary of the blood pressure readingsand anti-hypertensive treatments of Subject 9, a 54-year-old man withlocally advanced adenocarcinoma of the head of the pancreas, throughouta Phase I clinical trial of OMP-21M18. Subject 9 was enrolled in the 10mg/kg OMP-21M18 cohort.

All of the tables in FIGS. 1-7 include the baseline blood pressure ofeach subject, before the start of treatment with OMP-21M18, and bloodpressure readings for each subject for every day of the study that bloodpressure readings were taken. For study days in which an infusion ofOMP-21M18 was administered, blood pressure readings include a readingpre-infusion, 15 minutes after the start of infusion, at the end ofinfusion, and 15 minutes post-infusion.

DESCRIPTION OF THE EMBODIMENTS Definitions

The term “antibody” is used to mean an immunoglobulin molecule thatrecognizes and specifically binds to a target, such as a protein,polypeptide, peptide, carbohydrate, polynucleotide, lipid, orcombinations of the foregoing through at least one antigen recognitionsite within the variable region of the immunoglobulin molecule. Incertain embodiments, antibodies of the present invention includeantagonist antibodies that specifically bind to DLL4. Such antibodiescan, for example, interfere with ligand binding, receptor dimerization,and/or downstream signaling of the DLL4 receptor.

As used herein, the term “antibody” encompasses intact polyclonalantibodies, intact monoclonal antibodies, antibody fragments (such asFab, Fab′, F(ab′)2, and Fv fragments), single chain Fv (scFv) mutants,multispecific antibodies such as bispecific antibodies generated from atleast two intact antibodies, chimeric antibodies, humanized antibodies,human antibodies, fusion proteins comprising an antigen determinationportion of an antibody, and any other modified immunoglobulin moleculecomprising an antigen recognition site so long as the antibodies exhibitthe desired biological activity. An antibody can be of any the fivemajor classes of immunoglobulins: IgA, IgD, IgE, IgG, and IgM, orsubclasses (isotypes) thereof (e.g. IgG1, IgG2, IgG3, IgG4, IgA1 andIgA2), based on the identity of their heavy-chain constant domainsreferred to as alpha, delta, epsilon, gamma, and mu, respectively. Thedifferent classes of immunoglobulins have different and well knownsubunit structures and three-dimensional configurations. Antibodies canbe naked or conjugated to other molecules such as toxins, radioisotopes,etc.

A “monoclonal antibody” as used herein refers to homogenous antibodypopulation involved in the highly specific recognition and binding of asingle antigenic determinant, or epitope. This is in contrast topolyclonal antibodies that typically include different antibodiesdirected against different antigenic determinants. The term “monoclonalantibody” encompasses both intact and full-length monoclonal antibodiesas well as antibody fragments (such as Fab, Fab′, F(ab′)2, Fv), singlechain (scFv) mutants, fusion proteins comprising an antibody portion,and any other modified immunoglobulin molecule comprising an antigenrecognition site. Furthermore, “monoclonal antibody” refers to suchantibodies made in any number of manners including but not limited to byhybridoma, phage selection, recombinant expression, and transgenicanimals.

As used herein, the term “humanized antibody” refers to forms ofnon-human (e.g. murine) antibodies that are specific immunoglobulinchains, chimeric immunoglobulins, or fragments thereof that containminimal non-human sequences. Typically, humanized antibodies are humanimmunoglobulins in which residues from the complementarity determiningregions (CDRs) within the antigen determination region (or hypervariableregion) of the variable region of an antibody chain or chains arereplaced by residues from the CDR of a non-human species (e.g. mouse,rat, rabbit, hamster) that have the desired specificity, affinity, andcapability. In some instances, residues from the variable chainframework region (FR) of a human immunoglobulin are replaced with thecorresponding residues in an antibody from a non-human species that hasthe desired specificity, affinity, and capability. The humanizedantibody can be further modified by the substitution of additionalresidues either in the variable framework region and/or within thereplaced non-human residues to refine and optimize antibody specificity,affinity, and/or capability. In general, the humanized antibody willcomprise substantially all of at least one, and typically two or threeor four, variable domains containing all or substantially all of the CDRregions that correspond to the non-human immunoglobulin whereas all orsubstantially all of the FR regions are those of a human immunoglobulinconsensus sequence. The humanized antibody can also comprise at least aportion of an immunoglobulin constant region or domain (Fc), typicallythat of a human immunoglobulin. Examples of methods used to generatehumanized antibodies are described in U.S. Pat. No. 5,225,539.

The term “human antibody,” as used herein, means an antibody produced bya human or an antibody having an amino acid sequence corresponding to anantibody produced by a human made using any technique known in the art.This definition of a human antibody includes intact or full-lengthantibodies, fragments thereof, and/or antibodies comprising at least onehuman heavy and/or light chain polypeptide such as, for example, anantibody comprising murine light chain and human heavy chainpolypeptides.

That an antibody “selectively binds” or “specifically binds” means thatthe antibody reacts or associates more frequently, more rapidly, withgreater duration, with greater affinity, or with some combination of theabove to an epitope than with alternative substances, includingunrelated proteins. “Selectively binds” or “specifically binds” meansthat an antibody binds to a protein at times with a K_(D) of about 0.1mM or lower, and at other times about 0.01 mM or lower. Because of thesequence identity between homologous proteins in different species,specific binding can include an antibody that recognizes a DLL4 proteinin more than one species.

The terms “epitope” or “antigenic determinant” are used interchangeablyherein and refer to that portion of an antigen capable of beingrecognized and specifically bound by a particular antibody. When theantigen is a polypeptide, epitopes can be formed both from contiguousamino acids and noncontiguous amino acids juxtaposed by tertiary foldingof a protein. Epitopes formed from contiguous amino acids are typicallyretained upon protein denaturing, whereas epitopes formed by tertiaryfolding are typically lost upon protein denaturing. An epitope typicallyincludes at least 3, and more usually, at least 5 or 8-10 amino acids ina unique spatial conformation.

As used herein, the term “hypertension” refers to a condition in which asubject exhibits abnormally elevated blood pressure. Hypertension isclassified as either essential hypertension (primary hypertension), inwhich no specific medical cause for the elevated blood pressure isfound, or secondary hypertension, in which elevated blood pressure isdue to a specific condition, such as kidney disease or tumors, or due toexposure to a substance that increases blood pressure. In general,hypertension in humans is considered to be present when a person's bloodpressure is consistently at least 140 mmHg systolic or 90 mmHgdiastolic. Prehypertension is considered to be present when a person'sblood pressure is in the range of 120-139 mmHg systolic or 80-89 mmHgdiastolic. While not necessarily problematic in itself, prehypertensioncan indicate that a person is at increased risk for developinghypertension.

As used herein, the term “anti-hypertensive agent” refers to anycompound that when administered to a subject reduces blood pressure. Inmedicine, anti-hypertensive drugs are used to treat hypertension. Thereare several classes of anti-hypertensive drugs, including diuretics,adrenergic receptor antagonists, adrenergic receptor agonists, calciumchannel blockers, ACE inhibitors, angiotensin II receptor antagonists,aldosterone antagonists, vasodilators, and renin inhibitors. Each ofthese groups of anti-hypertensive drugs acts to reduce blood pressurethrough a different mechanism.

As used herein, the terms “cancer” and “cancerous” refer to or describethe physiological condition in mammals in which a population of cellsare characterized by unregulated cell growth. Examples of cancerinclude, but are not limited to, carcinoma, lymphoma, blastoma, sarcoma,and leukemia. More particular examples of solid tumor cancers includesquamous cell cancer, small-cell lung cancer, non-small cell lungcancer, adenocarcinoma of the lung, squamous carcinoma of the lung,cancer of the peritoneum, hepatocellular cancer, gastrointestinalcancer, pancreatic cancer, glioblastoma, cervical cancer, ovariancancer, liver cancer, bladder cancer, hepatoma, breast cancer, coloncancer, colorectal cancer, endometrial or uterine carcinoma, salivarygland carcinoma, kidney cancer, liver cancer, prostate cancer, vulvalcancer, thyroid cancer, hepatic carcinoma, and various types of head andneck cancers.

As used herein, the terms “subject” or “patient” refers to any animal(e.g., a mammal), including, but not limited to humans, non-humanprimates, rodents, and the like, which is to be the recipient of aparticular treatment. Typically, the teens “subject” and “patient” areused interchangeably herein in reference to a human subject.

“Pharmaceutically acceptable carrier, excipient, or adjuvant” refers toa carrier, excipient, or adjuvant that can be administered to a subjecttogether with the anti-DLL4 antibody and/or one or moreanti-hypertensive agent of the invention, and which does not destroy thepharmacological activity thereof and is nontoxic when administered indoses sufficient to deliver a therapeutic amount of the compound.Pharmaceutically acceptable carriers, excipients or adjuvants are oftenlisted in the U.S. Pharmacopeia or other generally recognizedpharmacopeia for use in animals, including humans.

The terms “effective amount” or “therapeutically effective amount”refers to an amount of an antibody, polypeptide, polynucleotide, smallorganic molecule, or other drug effective to “treat” a disease ordisorder in a subject or mammal. In the case of cancer, thetherapeutically effective amount of the drug can reduce the number ofcancer cells; reduce the tumor size; inhibit or stop cancer cellinfiltration into peripheral organs including, for example, the spreadof cancer into soft tissue and bone; inhibit and stop tumor metastasis;inhibit and stop tumor growth; relieve to some extent one or more of thesymptoms associated with the cancer, reduce morbidity and mortality;improve quality of life; or a combination of such effects. To the extentthe drug prevents growth and/or kills existing cancer cells, it can bereferred to as cytostatic and/or cytotoxic. In the case of hypertension,a therapeutically effective amount of the anti-hypertensive agent canreduce the blood pressure of a subject or prevent a subject's bloodpressure from rising. Preferably, the therapeutically effective amountof the anti-hypertensive agent will reduce a subject's blood pressure toclinically defined “normal” levels or maintain a subject's bloodpressure within normal bounds.

Terms such as “treating” or “treatment” or “to treat” or “alleviating”or “to alleviate” or “ameliorating” or “to ameliorate” refer to both 1)therapeutic measures that cure, slow down, lessen symptoms of, and/orhalt progression of a diagnosed pathologic condition or disorder and 2)prophylactic or preventative measures that prevent and/or slow thedevelopment of a targeted pathologic condition or disorder. Thus thosein need of treatment include those already with the disorder; thoseprone to have the disorder; and those in whom the disorder is to beprevented. In certain embodiments, a subject is successfully “treated”according to the methods of the present invention if the patient showsone or more of the following: a reduction in the number of or completeabsence of cancer cells; a reduction in the tumor size; inhibition of oran absence of cancer cell infiltration into peripheral organs including,for example, the spread of cancer into soft tissue and bone; inhibitionof or an absence of tumor metastasis; inhibition or an absence of tumorgrowth; relief of one or more symptoms associated with the specificcancer; reduced morbidity and mortality; improvement in quality of life;a reduction in blood pressure or stable maintenance of blood pressure ator about clinically normal levels; or some combination of effects.

DLL4 Antibodies

In certain embodiments, the DLL4 antagonists are antibodies, such asantibodies that bind specifically to DLL4 (i.e., anti-DLL4 antibodies).In certain embodiments, the antibodies specifically bind human DLL4.

Anti-DLL4 antibodies can act as DLL4 antagonists by binding to DLL4 andblocking its binding to the Notch receptor. The DLL4 antibodies of theinvention can be prepared by any conventional means known in the art. Incertain embodiments, the Dll4 antibodies are dysangiogenic.

In certain embodiments, the anti-DLL4 antibody is a monoclonal antibody.Monoclonal antibodies can be prepared by any conventional means known inthe art (Goding, Monoclonal Antibodies: Principles and Practice,Academic Press, 1986). Monoclonal antibodies can be prepared usinghybridoma methods, such as those described by Kohler and Milstein (1975)Nature 256:495. Alternatively, monoclonal antibodies can also be madeusing recombinant DNA methods as described in U.S. Pat. No. 4,816,567.Recombinant monoclonal antibodies or fragments thereof of the desiredspecies can also be isolated from phage display libraries expressingCDRs of the desired species as described (McCafferty et al., 1990,Nature, 348:552-554; Clackson et al., 1991, Nature, 352:624-628; andMarks et al., 1991, J. Mol. Biol., 222:581-597).

In some embodiments of the present invention, the anti-DLL4 antibody isa humanized antibody. Humanized antibodies are antibodies that containminimal sequences from non-human (e.g murine) antibodies within thevariable regions. Such antibodies are used therapeutically to reduceantigenicity and HAMA (human anti-mouse antibody) responses whenadministered to a human subject. Humanized antibodies can be producedusing various techniques known in the art (Jones et al., 1986, Nature,321:522-525; Riechmann et al., 1988, Nature, 332:323-327; Verhoeyen etal., 1988, Science, 239:1534-1536). An antibody can be humanized bysubstituting the CDRs of a human antibody with that of a non-humanantibody (e.g. mouse, rat, rabbit, hamster, etc.) having the desiredspecificity, affinity, and/or capability. The humanized antibody can befurther modified by the substitution of additional residue either in thevariable human framework region and/or within the replaced non-humanresidues to refine and optimize antibody specificity, affinity, and/orcapability.

In other embodiments, the anti-DLL4 antibody is a fully human antibody.Human antibodies can be prepared using various techniques known in theart. Immortalized human B lymphocytes immunized in vitro or isolatedfrom an immunized individual that produce an antibody directed against atarget antigen can be generated (See, e.g., Cole et al., MonoclonalAntibodies and Cancer Therapy, Alan R. Liss, p. 77 (1985); Boerner etal., 1991, J. Immunol., 147 (1):86-95; and U.S. Pat. No. 5,750,373).Also, the human antibody can be selected from a phage library, wherethat phage library expresses human antibodies (Vaughan et al., 1996,Nat. Biotech., 14:309-314; Sheets et al., 1998, Proc. Nat'l. Acad. Sci.,95:6157-6162; Hoogenboom and Winter, 1991, J. Mol. Biol., 227:381; Markset al., 1991, J. Mol. Biol., 222:581). Human antibodies can also be madein transgenic mice containing human immunoglobulin loci that are capableupon immunization of producing the full repertoire of human antibodiesin the absence of endogenous immunoglobulin production. This approach isdescribed in U.S. Pat. Nos. 5,545,807; 5,545,806; 5,569,825; 5,625,126;5,633,425; and 5,661,016.

In certain embodiments, the anti-DLL4 antibody specifically binds to ahuman DLL4 epitope in the amino-terminal region (SEQ ID NO: 11). Incertain embodiments, the anti-Dll4 antibody binds to the DSL domain. Incertain embodiments, the anti-Dll4 antibody binds to both the DSL domainand/or the amino-terminal region of Dll4.

In certain embodiments, the anti-DLL4 antibody is the antibody producedby the hybridoma deposited with ATCC on Sep. 28, 2007 and having ATCCdeposit number PTA-8670, also known as murine 21M18. The murine 21M18antibody is described in detail in co-pending U.S. patent applicationSer. No. 11/905,392, Publication No. 2008/0187532, filed Sep. 28, 2007,incorporated herein by reference in its entirety.

In certain embodiments, the anti-DLL4 antibody is the antibody encodedby the plasmid deposited with ATCC on May 10, 2007, having ATCC depositnumber PTA-8425, also known as 21M18 H7L2 and OMP-21M18. The OMP-21M18antibody is described in detail in co-pending U.S. patent applicationSer. No. 11/905,392, Publication No. 2008/0187532, filed Sep. 28, 2007.The anti-DLL4 antibody OMP-21M18 comprises a heavy chain variable regioncomprising CDR amino acid sequences CDR1 (SEQ ID NO: 1); CDR2 (SEQ IDNO: 2, SEQ ID NO: 3, or SEQ ID NO: 4); and CDR3 (SEQ ID NO: 5); and alight chain variable region comprising CDR amino acid sequences CDR1(SEQ ID NO: 7); CDR2 (SEQ ID NO: 8); and CDR3 (SEQ ID NO: 9). In oneembodiment, the OMP-21M18 antibody comprises the heavy chain sequence ofSEQ ID NO:6 and the light chain sequence of SEQ ID NO: 10.

In certain embodiments, the anti-DLL4 antibody is the antibody encodedby the plasmid deposited with ATCC on May 10, 2007, having ATCC depositnumber PTA-8427, also known as 21M18 H9L2. The 21M18 H9L2 antibody isdescribed in detail in co-pending U.S. patent application Ser. No.11/905,392, Publication No. 2008/0187532, filed Sep. 28, 2007.

In certain embodiments, the anti-DLL4 antibody is an antibody thatcompetes with the antibody OMP-21M18 for specific binding to human DLL4.

Other anti-DLL4 antibodies are known in the art. Anti-DLL4 antibodiesare available from commercial sources (for example, Santa CruzBiotechnology, Inc. catalog no. sc-73900 is a rat IgG_(2a) antibody thatbinds to the extracellular domain of human DLL4). In some embodiments,the DLL4 antagonist can be one of the anti-DLL4 antibodies described inU.S. patent application Ser. No. 12/002,245, filed Dec. 14, 2007, andpublished as U.S. Patent Application Pub. No. 2008/0181899; U.S. Pat.No. 7,488,806, filed Oct. 3, 2008, and published as U.S. PatentApplication Pub. No. 2009/0017035; and U.S. Pat. No. 7,534,868, filedFeb. 13, 2009, and published as U.S. Patent Application Pub. No.2009/0142354. The foregoing patents and applications disclose fullyhuman anti-DLL4 antibodies generated using VELOCIMMUNE™ technology(Regeneron Pharmaceuticals, Inc.). Certain of these antibodies, denotedREGN281, REGN 421, and REGN 422 are described as blocking DLL4 bindingto the Notch receptor.

In other embodiments, the DLL4 antagonist can be one of the anti-DLL4antibodies described in U.S. patent application Ser. No. 11/759,131,filed Jun. 6, 2007, and published as U.S. Patent Application Pub. No.2008/0175847; and U.S. patent application Ser. No. 11/759,093, filedJun. 6, 2007, and published as U.S. Patent Application Pub. No.2008/0014196 (now abandoned). The foregoing applications disclose humananti-DLL4 antibodies that are described as binding to the extracellulardomain of DLL4. These antibodies were isolated by screening a syntheticphage antibody library (Genentech, Inc.).

Anti-Hypertensive Agents

The anti-hypertensive agents useful in the present invention fall intoseveral classes, including: diuretics, adrenergic receptor antagonists,adrenergic receptor agonists, calcium channel blockers,Angiotensin-Converting Enzyme (ACE) inhibitors, angiotensin II receptorantagonists, aldosterone antagonists, vasodilators, and renininhibitors.

Diuretics are a class of drugs that elevate the rate of urination andthus provides a means of forced diuresis. There are several categoriesof diuretics, including high ceiling loop diuretics, thiazides,potassium-sparing diuretics, calcium-sparing diuretics, osmoticdiuretics, and low ceiling diuretics. All diuretics increase theexcretion of water from the body, although each class does so in adistinct way. Diuretics include but are not limited to: loop diureticssuch as furosemide, bumetanide, ethacrynic acid, and torsemide; thiazidediuretics such as epitizide, hydrochlorothiazide, hydroflumethiazide,chlorothiazide, bendroflumethiazide, polythiazide, trichlormethiazide,cyclopenthiazide, methyclothiazide, cyclothiazide, mebutizide, and otherbenzothiadiazine derivatives; thiazide-like diuretics such asindapamide, chlortalidone, metolazone, quinethazone, clopamide,mefruside, clofenamide, meticrane, xipamide, clorexolone, andfenquizone; potassium-sparing diuretics such as amiloride, triamterene,eplerenone, benzamil, potassium canrenoate, canrenone, andspironolactone; osmotic diuretics such as mannitol, glucose, and urea;vasopressin receptor antagonists such as conivaptan, relcovaptan,nelivaptan, lixivaptan, mozavaptan, satavaptan, tolvaptan, anddemeclocycline; mercurial diuretics such as mersalyl acid (Mersal),meralluride, mercaptomerin, mercurophylline, merethoxylline procaine,and calomel; xanthine diuretics such as caffeine, theobromine,paraxanthine, and theophylline; carbonic anhydrase inhibitors such asacetazolamide, methazolamide, dorzolamide, sulfonamide, and topiramate;other diuretics such as diuretic purines, diuretic steroids, diureticsulfonamide derivatives, diuretic uracils, amanozine, arbutin,chlorazanil, etozolin, hydracarbazine, isosorbide, metochalcone,muzolimine, perhexyline, ticrynafen, triamterene, and spironolactone.

Adrenergic receptor antagonists can be divided into two sub-categories:beta-adrenergic antagonists (“beta blockers”) and alpha-adrenergicantagonists (“alpha blockers”). Adrenergic receptor antagonists includebut are not limited to: beta-adrenergic antagonists such as atenolol,metoprolol, nadolol, oxprenolol, pindolol, propranolol, timolol,acebutolol, bisoprolol, esmolol, labetalol, carvedilol, bucindolol,nebivolol, alprenolol; amosulalol, arotinolol, befunolol, betaxolol,bevantolot, bopindolol, bucumolol, bufetolol, bufuralol, bunitrolol,bupranolol, butidrine hydrochloride, butofilolol, carazolol, carteolol,celiprolol, cetamolol, cloranololdilevalol, epanolol, indenolol,levobunolol, mepindolol, metipranolol, moprolol, nadoxolol, nipradilol,penbutolol, practolol, pronethalol, sotalol, sulfinalol, talinolol,tertatolol, tilisolol, toliprolol, and xibenolol; and alpha-adrenergicantagonists such as phenoxybenzamine, prazosin, doxazosin, terazosin,trimazosin, phentolamine, amosulalol, arotinolol, dapiprazole,fenspiride, indoramin, labetalol, naftopidil, nicergoline, tamsulosin,tolazoline, reserpine, moxonidine and yohimbine.

Adrenergic receptor agonists include but are not limited to: clonidine,methyldopa, guanfacine, methoxamine, methylnorepinephrine,oxymetazoline, phenylephrine, guanabenz, guanoxabenz, guanethidine,xylazine, and tizanidine.

Calcium channel blockers block voltage-gated calcium channels in cardiacmuscle and blood vessels, leading to a reduction in muscle contraction.This leads to vasodilation and a decrease in blood pressure. Calciumchannel blockers include but are not limited to: dihydropyridines suchas amlodipine, felodipine, nicardipine, nifedipine, nimodipine,isradipine, nitrendipine, aranidipine, barnidipine, benidipine,cilnidipine, efonidipine, elgodipine, lacidipine, lercanidipine,manidipine, nilvadipine, and nisoldipine; and non-dihydropyridines suchas diltiazem, verapamil, bepridil, clentiazem, fendiline, gallopamil,mibefradil, prenylamine, semotiadil, terodiline, cinnarizine,flunarizine, lidoflazine, lomerizine, bencyclane, etafenone, andperhexyline.

Angiotensin-Converting Enzyme (ACE) inhibitors treat hypertension bylowering arteriolar resistance and increasing venous capacity,increasing cardiac output and cardiac index, stroke work and volume,lowering renovascular resistance, and increasing excretion of sodium inthe urine. ACE inhibitors include but are not limited to:sulfhydryl-containing agents such as captopril and zofenopril;dicarboxylate-containing agents such as enalapril, ramipril, quinapril,perindopril, lisinopril, and benazepril; phosphonate-containing agentssuch as fosinopril and ceronapril, naturally occurring ACE inhibitorssuch as casokinins, lactokinins; tripeptides such as Val-Pro-Pro andIle-Pro-Pro and the nonapeptide teprotide; and other ACE inhibitors suchalacepril, cilazapril, delapril imidapril moexipril, rentiapril,spirapril, temocapril, moveltipril and trandolapril.

Angiotensin II receptor antagonists block the activation of angiotensinII AT₁ receptors, causing vasodilation, reduced secretion ofvasopressin, and reduced production and secretion of aldosterone, whichresults in the reduction of blood pressure. Angiotensin II receptorantagonists include but are not limited to: candesartan, eprosartan,irbesartan, losartan, olmesartan, telmisartan, and valsartan.

Aldosterone antagonists block the mineralocorticoid receptor resultingin inhibition of sodium resorption in the collecting duct of the nephronin the kidneys. This interferes with sodium/potassium exchange, reducingurinary potassium excretion and weakly increasing water excretion,leading to a diuretic effect. Aldosterone antagonists include but arenot limited to: eplerenone, canrenone, and spironolactone.

Vasodilators work by a wide variety of mechanisms, but all lead to therelaxation of smooth muscle cells within blood vessel walls, and thusthe widening of blood vessels. The widening of blood vessels leads toincreased blood flow and reduced vascular resistance, and thereforelower blood pressure. Vasodilators include but are not limited to:cerebral vasodilators such as bencyclane, cinnarizine, citicoline,cyclandelate, ciclonicate, diisopropylamine dichloroacetate,eburnamonine, fasudil, fenoxedil, flunarizine, ibudilast, ifenprodil,lomerizine, nafronyl, nicametate, nicergoline, nimodipine, papaverine,tinofedrine, vincamine, vinpocetine, and viquidil; coronary vasodilatorssuch as amotriphene, bendazol, benfurodil hemisuccinate, benziodarone,chloracizine, chromonar, clobenfural, clonitrate, cloricromen, dilazep,dipyridamole, droprenilamine, efloxate, erythrityl tetranitrate,etafenone, fendiline, floredil, ganglefene, hexestrolbis(β-diethylaminoethyl)ether, hexobendine, itramin tosylate, khellin,lidoflazine, mannitol hexanitrate, medibazine, nitroglycerin,pentaerythritol tetranitrate, pentrinitrol, perhexyline, pimethylline,prenylamine, propatyl nitrate, trapidil, tricromyl, trimetazidine,trolnitrate phosphate, sildenafil, tadalafil, vardenafil, sodiumnitroprusside, isosorbide mononitrate, isosorbide dinitrate,pentaerythritol tetranitrate, theobromine, and visnadine; and peripheralvasodilators such as aluminium nicotinate, bamethan, bencyclane,betahistine, bradykinin, brovincamine, bufeniode, buflomedil,butalamine, cetiedil, ciclonicate, cinepazide, cinnarizine,cyclandelate, diisopropylamine dichloroacetate, eledoisin, fenoxedil,flunarizine, hepronicate, ifenprodil, iloprost, inositol niacinate,isoxsuprine, kallidin, kallikrein, moxisylyte, nafronyl, nicametate,nicergoline, nicofuranose, nylidrin, pentifylline, pentoxifylline,piribedil, prostaglandin E1, suloctidil, tolazoline, and xanthinolniacinate.

Renin inhibitors act on the juxtaglomerular cells of kidney, whichproduce renin in response to decreased blood flow. Renin inhibitorsinclude but are not limited to: aliskiren and remikiren.

Other anti-hypertensives, not listed above, are also contemplated foruse in the invention. A skilled artisan would recognize that anycompound that acts to reduce blood pressure when administered to asubject could be used as the anti-hypertensive agent of the presentinvention.

Pharmaceutical Composition

The pharmaceutical compositions of the present invention comprise ananti-DLL4 antibody and one or more anti-hypertensive agents. Thepharmaceutical compositions of the present invention can be prepared forstorage and use by combining an anti-DLL4 antibody and one or moreanti-hypertensive agent with a pharmaceutically acceptable carrier (e.g.a vehicle or excipient). In other embodiments, the anti-DLL4 antibodyand the one or more anti-hypertensive agents are in separatecompositions, wherein those compositions are each formulated withpharmaceutically acceptable carriers appropriate for each agent.

Examples of suitable pharmaceutical carriers are described in“Remington, The Science and Practice of Pharmacy 20th Edition MackPublishing, 2000.” Suitable pharmaceutically acceptable vehiclesinclude, but are not limited to, nontoxic buffers such as phosphate,citrate, and other organic acids; salts such as sodium chloride;antioxidants including ascorbic acid and methionine; preservatives (e.g.octadecyldimethylbenzyl ammonium chloride; hexamethonium chloride;benzalkonium chloride; benzethonium chloride; phenol, butyl or benzylalcohol; alkyl parabens, such as methyl or propyl paraben; catechol;resorcinol; cyclohexanol; 3-pentanol; and m-cresol); low molecularweight polypeptides (e.g. less than about 10 amino acid residues);proteins such as serum albumin, gelatin, or immunoglobulins; hydrophilicpolymers such as polyvinylpyrrolidone; amino acids such as glycine,glutamine, asparagine, histidine, arginine, or lysine; carbohydratessuch as monosaccharides, disaccharides, glucose, mannose, or dextrins;chelating agents such as EDTA; sugars such as sucrose, mannitol,trehalose or sorbitol; salt-forming counter-ions such as sodium; metalcomplexes (e.g. Zn-protein complexes); and non-ionic surfactants such asTWEEN, polyethylene glycol (PEG), or polysorbate surfactants such asPolysorbate 20.

The pharmaceutical compositions of the present invention can beformulated for systemic or local administration. Examples of routes ofadministration include parenteral (e.g., intravenous, intradermal,subcutaneous), oral (e.g., inhalation), transmucosal, and rectaladministration.

Pharmaceutical compositions suitable for parenteral administrationinclude sterile aqueous solutions (where water soluble) or dispersionsand sterile powders for the extemporaneous preparation of sterileinjectable solutions or dispersion. For intravenous administration,suitable carriers include water for injection, physiological saline,bacteriostatic water, Cremophor EL (BASF, Parsippany, N.J.), phosphatebuffered saline (PBS), fixed oils, ethanol, polyethylene glycols,glycerine, propylene glycol or other synthetic solvents. In all cases,the composition must be sterile and should be fluid to the extent thateasy syringeability exists. The proper fluidity can be maintained, forexample, by the use of a coating such as lecithin, by the maintenance ofthe required particle size in the case of a dispersion, and by the useof surfactants. The pharmaceutical composition must be stable under theconditions of manufacture and storage and must be preserved against thecontaminating action of microorganisms such as bacteria and fungi.Prevention of the action of microorganisms can be achieved by variousantibacterial and antifungal agents, for example, benzyl alcohol,parabens, chlorobutanol, phenol, antioxidants such as ascorbic acid orsodium bisulfite, chelating agents such as ethylenediaminetetraaceticacid, thimerosal, and the like. In many cases, it will be preferable toinclude isotonic agents such as sugars, polyalcohols such as mannitoland sorbitol, or sodium chloride in the composition. Prolongedabsorption of the injectable compositions can be brought about byincluding in the composition an agent which delays absorption, forexample, aluminum monostearate and gelatin. The pH can be adjusted withacids or bases, such as hydrochloric acid or sodium hydroxide. Theparenteral preparation is enclosed in ampoules, disposable syringes ormultiple dose vials made of glass or plastic.

Sterile injectable solutions are prepared by incorporating the activecompound (e.g., an anti-DLL4 antibody and an anti-hypertensive agent) inthe required amount in an appropriate solvent with one or a combinationof ingredients enumerated above, as required, followed by filtersterilization. Generally, dispersions are prepared by incorporating theactive compounds into a sterile vehicle that contains a basic dispersionmedium and the required other ingredients from those enumerated above.In the case of sterile powders for the preparation of sterile injectablesolutions, methods of preparation are vacuum drying and freeze-dryingthat yield a powder of the active ingredient plus any additional desiredingredient from a previously sterile-filtered solution thereof.

In certain embodiments, the anti-DLL4 antibody can be prepared for useat a concentration of 10 mg/mL in a solution of 50 mM histidine, 100 mMsodium chloride, 45 mM sucrose, and 0.01% (w/v) Polysorbate 20, and thepH adjusted to 6.0.

The pharmaceutical compositions of the invention can include theanti-DLL4 antibody and/or anti-hypertensive agent complexed withliposomes (Epstein, et al., 1985, Proc. Natl. Acad. Sci. USA 82:3688;Hwang, et al., 1980, Proc. Natl. Acad. Sci. USA 77:4030; and U.S. Pat.Nos. 4,485,045 and 4,544,545). Liposomes with enhanced circulation timeare disclosed in U.S. Pat. No. 5,013,556. Some liposomes can begenerated by the reverse phase evaporation with a lipid compositioncomprising phosphatidylcholine, cholesterol, and PEG-derivatizedphosphatidylethanolamine (PEG-PE). Liposomes are extruded throughfilters of defined pore size to yield liposomes with the desireddiameter.

The anti-DLL4 antibody and/or the anti-hypertensive agent can also beentrapped in microcapsules. Such microcapsules are prepared, forexample, by coacervation techniques or by interfacial polymerization,for example, hydroxymethylcellulose or gelatin-microcapsules andpoly-(methylmethacylate) microcapsules, respectively, in colloidal drugdelivery systems (for example, liposomes, albumin microspheres,microemulsions, nano-particles and nanocapsules) or in macroemulsions asdescribed in “Remington, The Science and Practice of Pharmacy 20th Ed.Mack Publishing (2000).”

In addition sustained-release preparations can be prepared. Suitableexamples of sustained-release preparations include semipermeablematrices of solid hydrophobic polymers containing the anti-DLL4 antibodyand/or the anti-hypertensive agent, which matrices are in the form ofshaped articles (e.g. films, or microcapsules). Examples ofsustained-release matrices include polyesters, hydrogels such aspoly(2-hydroxyethyl-methacrylate) or poly(vinylalcohol), polylactides(U.S. Pat. No. 3,773,919), copolymers of L-glutamic acid and 7ethyl-L-glutamate, non-degradable ethylene-vinyl acetate, degradablelactic acid-glycolic acid copolymers such as the LUPRON DEPOT™(injectable microspheres composed of lactic acid-glycolic acid copolymerand leuprolide acetate), sucrose acetate isobutyrate, andpoly-D-(−)-3-hydroxybutyric acid.

Oral compositions generally include an inert diluent or an ediblecarrier. They can be enclosed in gelatin capsules or compressed intotablets. For the purpose of oral therapeutic administration, the activecompound is incorporated with excipients and used in the form oftablets, troches, or capsules. Pharmaceutically compatible bindingagents, and/or adjuvant materials can be included as part of thecomposition. The tablets, pills, capsules, troches and the like cancontain any of the following ingredients, or compounds of a similarnature: a binder such as microcrystalline cellulose, gum tragacanth orgelatin; an excipient such as starch or lactose, a disintegrating agentsuch as alginic acid, Primogel, or corn starch; a lubricant such asmagnesium stearate or Sterotes; a glidant such as colloidal silicondioxide; a sweetening agent such as sucrose or saccharin; or a flavoringagent such as peppermint, methyl salicylate, or orange flavoring. Thetablets, pills, etc of the novel composition can be coated or otherwisecompounded to provide a dosage form affording the advantage of prolongedaction. For example, the tablet or pill can comprise an innercomposition covered by an outer component. Furthermore, the twocomponents can be separated by an enteric layer that serves to resistdisintegration and permits the inner component to pass intact throughthe stomach or to be delayed in release. A variety of materials can beused for such enteric layers or coatings, such materials including anumber of polymeric acids and mixtures of polymeric acids with suchmaterials as shellac, cetyl alcohol and cellulose acetate.

For administration by inhalation, the compounds are delivered in theform of an aerosol spray from a pressured container or dispenser whichcontains a suitable propellant, e.g., a gas such as carbon dioxide, or anebulizer.

Administration can also be transmucosal or transdermal. For transmucosalor transdermal administration, penetrants appropriate to the barrier tobe permeated are used in the formulation. Such penetrants are generallyknown in the art, and include, for example, for transmucosaladministration, detergents, bile salts, and fusidic acid derivatives.Transmucosal administration can be accomplished through the use of nasalsprays or suppositories. For transdermal administration, the activecompounds are formulated into ointments, salves, gels, or creams asgenerally known in the art.

Combination Therapies

In certain embodiments, the anti-DLL4 antibody and the anti-hypertensiveagent can be administered in combination with one or more additionalcompounds or therapies for the treatment of cancer. Such additionalanti-cancer compounds include: cytotoxic agents, chemotherapeuticagents, growth inhibitory agents, or therapeutic antibodies. Whereseparate pharmaceutical compositions are used, the anti-DLL4 antibodyand one or more additional agents can be administered concurrently, orsequentially.

“Cytotoxic agents” inhibit or prevent the function of cells and/orcauses destruction of cells. Cytotoxic agents include but are notlimited to: radioactive isotopes (e.g. I¹³¹, I¹²⁵, Y⁹⁰ and Re¹⁸⁶), andtoxins such as enzymatically active toxins of bacterial, fungal, plantor animal origin, or fragments thereof.

“Chemotherapeutic agents” are chemical compounds useful in the treatmentof cancer. Chemotherapeutic agents include but are not limited to:alkylating agents such as thiotepa and cyclosphosphamide (CYTOXAN™);alkyl sulfonates such as busulfan, improsulfan and piposulfan;aziridines such as benzodopa, carboquone, meturedopa, and uredopa;ethylenimines and methylamelamines including altretamine,triethylenemelamine, trietylenephosphoramide,triethylenethiophosphaoramide and trimethylolomelamine; nitrogenmustards such as chlorambucil, chlornaphazine, cholophosphamide,estramustine, ifosfamide, mechlorethamine, mechlorethamine oxidehydrochloride, melphalan, novembichin, phenesterine, prednimustine,trofosfamide, uracil mustard; nitrosureas such as carmustine,chlorozotocin, fotemustine, lomustine, nimustine, ranimustine;antibiotics such as aclacinomysins, actinomycin, authramycin, azaserine,bleomycins, cactinomycin, calicheamicin, carabicin, caminomycin,carzinophilin, chromomycins, dactinomycin, daunorubicin, detorubicin,6-diazo-5-oxo-L-norleucine, doxorubicin, epirubicin, esorubicin,idarubicin, marcellomycin, mitomycins, mycophenolic acid, nogalamycin,olivomycins, peplomycin, potfiromycin, puromycin, quelamycin,rodorubicin, streptonigrin, streptozocin, tubercidin, ubenimex,zinostatin, zorubicin; anti-metabolites such as methotrexate and5-fluorouracil; folic acid analogues such as denopterin, methotrexate,pteropterin, trimetrexate; purine analogs such as fludarabine,6-mercaptopurine, thiamiprine, thioguanine; pyrimidine analogs such asancitabine, azacitidine, 6-azauridine, carmofur, cytarabine,dideoxyuridine, doxifluridine, enocitabine, floxuridine; androgens suchas calusterone, dromostanolone propionate, epitiostanol, mepitiostane,testolactone; anti-adrenals such as aminoglutethimide, mitotane,trilostane; folic acid replenisher such as frolinic acid; aceglatone;aldophosphamide glycoside; aminolevulinic acid; amsacrine; bestrabucil;bisantrene; edatraxate; defofamine; demecolcine; diaziquone;elformithine; elliptinium acetate; etoglucid; gallium nitrate;hydroxyurea; lentinan; lonidamine; mitoguazone; mitoxantrone; mopidamol;nitracrine; pentostatin; phenamet; pirarubicin; podophyllinic acid;2-ethylhydrazide; procarbazine; PSK™; razoxane; sizofuran;spirogermanium; tenuazonic acid; triaziquone;2,2′,2″-trichlorotriethylamine; urethan; vindesine; dacarbazine;mannomustine; mitobronitol; mitolactol; pipobroman; gacytosine;arabinoside (“Ara-C”); cyclophosphamide; thiotepa; taxanes, e.g.paclitaxel (TAXOL™, Bristol-Myers Squibb Oncology, Princeton, N.J.) anddocetaxel (TAXOTERE™; Aventis Antony, France); chlorambucil;gemcitabine; 6-thioguanine; mercaptopurine; methotrexate; platinumanalogs such as cisplatin and carboplatin; vinblastine; platinum;etoposide (VP-16); ifosfamide; mitomycin C; mitoxantrone; vincristine;vinorelbine; navelbine; novantrone; teniposide; daunomycin; aminopterin;capecitabine; ibandronate; CPT-11; topoisomerase inhibitor RFS 2000;difluoromethylornithine; retinoic acid; esperamicins; capecitabine; andpharmaceutically acceptable salts, acids or derivatives of any of theabove. Also included are anti-hormonal agents that act to regulate orinhibit hormone action on tumors such as anti-estrogens including forexample tamoxifen, raloxifene, aromatase inhibiting 4(5)-imidazoles,4-hydroxytamoxifen, trioxifene, keoxifene, LY 117018, onapristone, andtoremifene (Fareston); and anti-androgens such as flutamide, nilutamide,bicalutamide, leuprolide, and goserelin; and pharmaceutically acceptablesalts, acids or derivatives of any of the above.

“Growth inhibitory agents” are compounds which inhibit growth of cells,especially cancer cells, either in vitro or in vivo. Growth inhibitoryagents include but are not limited to: agents that block cell cycleprogression, such as vincas (vincristine and vinblastine), TAXOL™, andtopo II inhibitors such as doxorubicin, epirubicin, daunorubicin,etoposide, bleomycin, DNA alkylating agents such as tamoxifen,prednisone, dacarbazine, mechlorethamine, cisplatin, methotrexate,5-fluorouracil, and ara-C.

“Therapeutic antibodies” include antibodies that are used tospecifically target cancer cells. Therapeutic antibodies include but arenot limited to: rituximab (Rituxan), cetuximab (Erbitux), ibritumomab(Zevalin), gemtuzumab (Mylotarg), trastuzumab (Herceptin), alemtuzumab(Campath), bevacizumab (Avastin), panitumumab (Vectibix), andtositumomab (Bexxar).

Methods of Administration

In order to control hypertension in subjects having the condition or atrisk for it, it can be desirable to co-administer the anti-DLL4 antibodyand one or more anti-hypertensive agent. In one embodiment, the use ofthe anti-DLL4 antibody and one or more anti-hypertensive agent isdirected for those subjects having hypertension or at risk for itsdevelopment.

The pharmaceutical composition of the present invention can beadministered in any number of ways for either local or systemictreatment. Administration can be topical (such as to mucous membranesincluding vaginal and rectal delivery) such as transdermal patches,ointments, lotions, creams, gels, drops, suppositories, sprays, liquidsand powders; pulmonary (e.g., by inhalation or insufflation of powdersor aerosols, including by nebulizer; intratracheal, intranasal,epidermal and transdermal); oral; or parenteral including intravenous,intraarterial, subcutaneous, intraperitoneal, intraocular orintramuscular injection or infusion; or intracranial (e.g., intrathecalor intraventricular) administration. The pharmaceutical composition ofthe invention can be administered by any convenient route, such asinfusion or bolus injection.

Administration can be acute (i.e., a single administration of thecomposition) or chronic (i.e., daily, weekly, monthly administration).

Administration of the anti-DLL4 antibody and the anti-hypertensive agentcan include co-administration, either in a single pharmaceuticalformulation or using separate formulations, or consecutiveadministration in either order but generally within a time period suchthat all active agents can exert their biological activitiessimultaneously. Preparation and dosing schedules for anti-hypertensiveagents can be used according to manufacturers' instructions or asdetermined empirically by the skilled practitioner.

For the treatment of cancer with an anti-DLL4 antibody, the appropriatedosage of the anti-DLL4 antibody can be determined by the treatingphysician. The size of a tumor, the presence of malignant disease, andthe extent of metastasis are factors to be considered when determining adosage. The anti-DLL4 antibody can be administered one time or over aseries of treatments lasting from several days to several months.Preferably, the anti-DLL4 antibody is administered chronically until acure is effected or a diminution of the disease state is achieved (e.g.reduction in tumor size). Optimal dosing schedules can be calculatedfrom measurements of drug accumulation in the body of the patient andwill vary depending on the relative potency of the individual anti-DLL4antibody. The administering physician can easily determine optimumdosages, dosing methodologies and repetition rates. In general, dosageis from 0.01 μg to 100 mg per kg of body weight, and can be given onceor more daily, weekly, monthly or yearly. Repetition rates can beestimated for dosing based on measured residence times andconcentrations of the drug in bodily fluids or tissues. The treatingphysician can monitor the disease state of the patient (i.e., increasesor decreases in tumor size, presence or spread of metastasis, appearanceof malignancies, quality of life) and adjust the dosage of the anti-DLL4antibody accordingly.

For treatment of cancer with an anti-DLL4 antibody, such as OMP-21M18,in certain embodiments, suitable dosages for intravenous administrationare between about 0.1 mg/kg and about 20 mg/kg. In certain embodiments,dosages of the anti-DLL4 antibody, such as OMP-21M18, are about 0.1mg/kg; about 0.2 mg/kg; about 0.5 mg/kg; about 1.0 mg/kg; about 2.5mg/kg; about 5.0 mg/kg; about 7.5 mg/kg; about 10 mg/kg; and about 15mg/kg. Administration can be daily, twice per week, once per week, onceevery other week, once every three weeks, monthly, or any other suitableinterval at the discretion of the treating physician. Dosages andintervals of administration can be adjusted to optimize treatmentefficacy.

For the treatment of hypertension, the appropriate dosage of theanti-hypertensive agent depends on the severity and course of thehypertension, the responsiveness of the subject, whether theanti-hypertensive is administered for therapeutic or preventativepurposes, the subject's previous therapy, the subject's clinicalhistory, and so on, at the discretion of the treating physician. Theanti-hypertensive agent can be administered one time or over a series oftreatments lasting from several days to several months. Preferably, theanti-hypertensive agent is administered chronically until treatment withthe anti-DLL4 antibody has ceased. Optimal dosing schedules can becalculated from measurements of drug accumulation in the body of thepatient and will vary depending on the relative potency of theindividual anti-hypertensive agent. Additionally, effective dosages foranti-hypertensive agents available commercially will be provided by themanufacturer. The administering physician can easily determine optimumdosages, dosing methodologies and repetition rates. In general, dosageis from 0.01 μg to 100 mg per kg of body weight, and can be given onceor more daily, weekly, monthly or yearly. The treating physician canestimate repetition rates for dosing based on measured residence timesand concentrations of the drug in bodily fluids or tissues. Furthermore,the treating physician can monitor the blood pressure of a subject andadjust the amount of an anti-hypertensive administered, the frequency ofdosing, or the particular anti-hypertensive used to suit the needs ofthe patient. In a human clinical setting non-invasive methods formeasuring blood pressure would be used. For example, a simple arm cuffor sphygmomanometer measure blood pressure directly using theoscillometric method or connected to a pulse transducer for continuousmeasurement. More than one anti-hypertensive medication can be usedconcurrently to effectively control hypertension in a subject receivingtreatment with an anti-DLL4 antibody.

The present invention provides methods of preventing hypertension in apatient receiving treatment with a DLL4 antagonist or an anti-DLL4antibody comprising administering to the patient an effective amount ofone or more anti-hypertensive agents. “Preventing hypertension” meansthat the patient's blood pressure is kept, on average, below the rangeconsidered to be hypertension throughout the course of treatment withthe DLL4 antagonist or anti-DLL4 antibody. A blood pressure consistentlyat or above 140 mmHg systolic or 90 mmHg diastolic is consideredhypertension. A blood pressure consistently in the range of 120-139 mmHgsystolic or 80-89 diastolic is considered pre-hypertension. Depending onthe tolerances of the treating physician, “preventing hypertension” canmean keeping a patient's blood pressure below the range consideredhypertension, or keeping a patient's blood pressure below the rangeconsidered pre-hypertension.

The present invention provides methods for monitoring a patientreceiving treatment with a DLL4 antagonist or an anti-DLL4 antibody forthe development of hypertension comprising measuring the blood pressureof the patient receiving treatment with the DLL4 antagonist or anti-DLL4antibody for a blood pressure elevated above the normal range andadministering to the patient with the elevated blood pressure one ormore anti-hypertensive agents. The treating physician can measure thepatient's blood pressure before, during, and after treatment with theDLL4 antagonist or anti-DLL4 antibody. Blood pressure measurement beforetreatment can be used to establish a baseline blood pressure. If thebaseline blood pressure is in the pre-hypertensive or hypertensiverange, the treating physician can opt to begin administration ofanti-hypertensive agents immediately, either before or concurrently withthe administration of the DLL4 antagonist or anti-DLL4 antibody. Bloodpressure monitoring of the patient would continue after initiation oftreatment with the DLL4 antagonist or anti-DLL4 antibody to ensure thatthe anti-hypertensive regimen is adequately controlling the patient'shypertension. If the baseline blood pressure is in the normal range, thetreating physician can opt to continue monitoring blood pressure aftertreatment with the DLL4 antagonist or anti-DLL4 antibody begins andinitiating treatment with anti-hypertensives only if the patient's bloodpressure rises. Alternatively, the treating physician can decide toprophylactically administer anti-hypertensives to a patient whosebaseline blood pressure is in the normal range to pre-empt thedevelopment of hypertension after treatment with the DLL4 antagonist oranti-DLL4 antibody begins.

After treatment with the DLL4 antagonist or anti-DLL4 antibody isinitiated, routine monitoring of the patient's blood pressure isperformed. Blood pressure readings can be taken at any appropriateinterval: daily, every other day, bi-weekly, weekly, biweekly, monthly,or at any interval deemed appropriate by the physician. If the bloodpressure of a patient becomes elevated into the hypertension range, thetreating physician can initiate anti-hypertensive treatment. Thedosages, particular anti-hypertensive medications used, and dosingschedule can be adjusted by the physician as necessary to adequatelycontrol the patient's hypertension. If the blood pressure of a patientbecomes elevated into the pre-hypertension range, the treating physiciancan initiate anti-hypertensive treatment or continue monitoring thepatient and begin anti-hypertensive treatment only if the patient'sblood pressure rises into the hypertension range. If the blood pressureof a patient becomes elevated significantly compared to the baselineblood pressure reading, but is not in the pre-hypertension orhypertension range, the treating physician can prophylactically initiateanti-hypertensive treatment to prevent the patient's blood pressure fromcontinuing to rise, or continue monitoring the patient and beginanti-hypertensive treatment only if the patient's blood pressure risesinto the pre-hypertension or hypertension range. If a patient isinitiated on anti-hypertensive treatment and their blood pressure doesnot decrease or continues to rise, the treating physician can increasethe dosage of the anti-hypertensive, add one or more additionalanti-hypertensive medications to the treatment regimen, change theanti-hypertensive medication, or take more than one of the precedingsteps in order to reduce the patient's blood pressure to an acceptablelevel.

Treatment Population

The pharmaceutical compositions and methods of the present invention canbe used to treat subjects suffering from cancer. In certain embodiments,the methods of the invention allow the treatment of subjects sufferingfrom cancer with an anti-DLL4 antibody at a dosage that could nototherwise be used without placing certain subjects at risk fordeveloping complications due to hypertension.

In certain embodiments, the subjects are those suffering fromhypertension or pre-hypertension prior to the start of therapy with ananti-DLL4 antibody, subjects over the age of 65 years old, subjects withor at risk for developing cardiovascular disease, or subjects whodevelop hypertension or pre-hypertension after the start of treatmentwith an anti-DLL4 antibody.

Subjects at risk for developing cardiovascular disease include thoseover 65 years of age, of the male sex, or who have hereditary factorslinked to cardiovascular disease. The risk of cardiovascular diseaseincreases with increasing age. Over 83 percent of people who die ofcoronary heart disease are 65 or older. Men overall have a higher riskof cardiovascular disease than women, and experience heart attacksearlier in life. Children of parents who had cardiovascular disease aremore likely than children of parents who did not have cardiovasculardisease to develop cardiovascular disease themselves, suggesting ahereditary link. Additionally, people of certain races are more likelyto develop cardiovascular disease than other races. For example, AfricanAmericans, Mexican Americans, native Hawaiians, and American Indianshave a greater risk of developing cardiovascular disease thanCaucasians.

Additionally, lifestyle factors can contribute to a subject's likelihoodof developing cardiovascular disease. Smoking, physical inactivity,excessive drinking of alcohol, high levels of stress, and obesity allincrease a subject's likelihood of developing cardiovascular disease.Preexisting conditions can also increase a subject's likelihood ofdeveloping cardiovascular disease. Diabetes mellitus, high bloodcholesterol, high blood pressure, and clogged arteries are all riskfactors for cardiovascular disease.

Subjects at risk for developing hypertension include those subjects over45 years of age, male subjects, or those with hereditary traits linkedto hypertension. The risk of hypertension increases with age. Males over45 years of age and women over 55 years of age are at an increased riskof developing hypertension. Additionally, men overall have a higher riskof hypertension than women.

Subjects whose blood pressure is in the range considered to be“pre-hypertension” are more likely than subjects whose blood pressure isin the normal range to develop hypertension.

The prevention or inhibition of hypertension is desirable in any subjectreceiving treatment with a DLL4 antagonist or anti-DLL4 antibody.Prevention or treatment of hypertension is particularly desirable insubjects who, prior to the start of treatment with a DLL4 inhibitor oranti-DLL4 antibody suffer from hypertension or pre-hypertension, are atrisk for developing cardiovascular disease, are at risk for developinghypertension, or have a condition which would be exacerbated byhypertension, such as heart failure, aneurysms, kidney disease, ornarrowed arteries.

In certain embodiments, the subjects to be treated with a Dll4antagonist do not have a prior history of hypertension. In certainalternative embodiments, the subjects do not have a prior history ofcardiovascular disease. Methods of monitoring such subjects for thedevelopment of hypertension, optionally followed by the subsequentadministration of anti-hypertensives if hypertension does develop, areprovided.

Methods of screening patients for treatment with a Dll4 antagonist, suchas an anti-Dll4 antibody, are also provided. In certain embodiments, themethods comprise selecting patients based on a lack of prior history ofhypertension and/or cardiovascular disease. Thus, in certain methods,the subjects having no prior history of hypertension (and/orcardiovascular disease) are treated with the Dll4 antagonist. In certainalternative embodiments, subjects having a prior history of hypertensionand/or cardiovascular disease are selected for treatment with both aDll4 antagonist and an anti-hypertensive.

The invention is not limited to the treatment of tumors or cancer, andincludes other, non-malignant diseases that are characterized by thepresence of vascular proliferation. Vascular Proliferation disordersinclude those of the eye such as Macular Degeneration and DiabeticRetinopathy.

Kits

The invention also provides kits comprising an anti-DLL4 antibody andanti-hypertensive agent and that can be used to perform the methodsdescribed herein. In certain embodiments, the kit comprises an anti-DLL4antibody and a package insert contained within a packaging material. Inother embodiments, the kit comprises an anti-DLL4 antibody, at least oneanti-hypertensive agent, and a package insert contained within apackaging material. The anti-DLL4 antibody and the one or moreanti-hypertensive agents can be admixed together in a singlepharmaceutical composition for concomitant administration, or can be inseparate containers for sequential or concomitant administration. Inother embodiments, the kit can also comprise one or more additionalanti-cancer therapeutic agents, such as a chemotherapeutic or atherapeutic antibody. In certain embodiments, the package insert willindicate that the anti-DLL4 antibody can be used for treating cancer orreducing tumor growth, that the anti-hypertensive agent can be used incombination with the anti-DLL4 antibody to reduce hypertension caused bythe administration of the anti-DLL4 antibody, or contain instructions onthe dosage, administration schedule, and monitoring of subjectsundergoing treatment with the anti-DLL4 antibody and anti-hypertensiveagent. One skilled in the art will readily recognize that the disclosedpharmaceutical compositions of the present invention can be readilyincorporated into one of the established kit formats which are wellknown in the art.

Embodiments of the present disclosure can be further defined byreference to the following examples. It will be apparent to thoseskilled in the art that many modifications, both to materials andmethods, can be practiced without departing from the scope of thepresent disclosure. As used herein and in the appended claims, thesingular forms “a,” “or,” and “the” include plural referents unless thecontext clearly dictates otherwise. Thus, for example, reference to “ananti-hypertensive agent” includes a plurality of such agents orequivalents thereof known to those skilled in the art. Furthermore, allnumbers expressing quantities of ingredients, dosage amounts, bloodpressure readings, and so forth, used in the specification, are modifiedby the term “about,” unless otherwise indicated. Accordingly, thenumerical parameters set forth in the specification and claims areapproximations that can vary depending upon the desired properties ofthe present invention.

EXAMPLES Example 1 Phase 1 Dose Escalation Study of OMP-21M18 inSubjects with Solid Tumors

Thirty-three subjects with advanced solid tumors initiated treatmentwith OMP-21M18 in a Phase I clinical trial. The trial was designed todetermine the maximum tolerated dose (MTD), safety, pharmacokinetics,immunogenicity, and preliminary efficacy of OMP-21M18 in subjects withadvanced solid tumors. All subjects had histologically confirmedmalignancies that were metastatic or unresectable and had receivedextensive treatment for their cancer. At the time of enrollment, therewas no remaining standard curative therapy and no therapy with ademonstrated survival benefit.

OMP-21M18 was prepared for use at a concentration of 10 mg/mL in asolution of 50 mM histidine, 100 mM sodium chloride, 45 mM sucrose, and0.01% (w/v) Polysorbate 20, with the pH adjusted to 6.0. Once prepared,OMP-21M18 was stored as 20 mL aliquots in 25-cc vials.

OMP-21M18 was administered at dosages of 0.5 mg/kg weekly to threesubjects, 1.0 mg/kg weekly to three subjects, 2.5 mg/kg every two weeksto six subjects, 2.5 mg/kg weekly to six subjects, 5.0 mg/kg every twoweeks to six subjects, 5.0 mg/kg weekly to three subjects, and 10.0mg/kg every two weeks to six subjects. According to the study protocol,the administration period was nine weeks, unless a subject was removedfrom the study due to a dose limiting toxicity. Baseline blood pressurereadings were taken just prior to administration of the first dosage.Toxicities were assessed using the National Institute of Health's CommonToxicity Criteria for Adverse Events (CTCAE) version 3.0. During thestudy, subjects were assessed for dose limiting toxicities from the timeof the first dose through 7 days after administration of the fourth dose(Days 0-28). Subjects who experienced a dose limiting toxicity had theirtreatment with OMP-21M18 permanently discontinued. After nine weeks oftreatment, if a subject continued to receive treatment and had noevidence of disease progression or if their tumor was smaller, thesubject was allowed to continue to receive IV infusions of OMP-21M18every other week until disease progression.

Twenty-two of the subjects treated in the trial had a prior diagnosis ofhypertension. Of these subjects, 8 were taking a single medication and 1subject each were taking two or three medications.

During the course of therapy, hypertension was reported for twelve ofthe thirty-three subjects, or 36% of patients treated with OMP-21M18. Ineleven of these subjects, the hypertension was labeled “grade three”because an oral anti-hypertensive medication was administered andadjusted to successfully control the subject's blood pressure. In theseeleven cases, the hypertension was asymptomatic and subjects were ableto continue treatment with OMP-21M18.

There appears to be a dose relationship to hypertension. Hypertensionhas been observed across the full range of doses, with the greatestincidence at the highest dose administered. At the 10.0 mg/kg doselevel, 6 of 6 subjects experienced Grade 3 hypertension (severe) orGrade 4 hypertension (life threatening).

TABLE 1 Incidence of Hypertension in Dosage Cohorts Grade 3 Grade 4Dosage Number of Hyper- Hyper- Total Incidence (mg/kg) Schedule Patientstension tension of Hypertension 0.5 weekly 3 1 0 1/3 1.0 weekly 3 1 01/3 2.5 every 2 6 1 0 1/6 weeks 2.5 weekly 6 2 0 2/6 5.0 every 2 6 1 01/3 weeks 5.0 weekly 3 0 0 0/3 10.0 every 2  6¹ 6 1 6/6 weeks ¹onepatient experienced both Grade 3 and Grade 4 hypertension

Example 2 Hypertension and Treatment in Subject No. 1

Subject 1, enrolled in the 0.5 mg/kg cohort, is a 78-year-old male withadenocarcinoma of the caecum with metastases to the liver. The Table ofFIG. 1 is a summary of Subject 1's blood pressure readings andanti-hypertensive treatments throughout the Phase I study of OMP-21M18.The subject's past medical history includes a diagnosis of hypertension,myocardial infarction (15 years prior), congestive heart failure, andparoxysmal atrial fibrillation. At study entry, the subject had beentaking benazepril hydrochloride (Lotensin®) 30 mg po qd for hypertensionfor the past five months. On Day 1, the subject's baseline bloodpressure was 135/73 mm Hg. On Day 0, the subject received his firstweekly dose of OMP-21M18 at 0.5 mg/kg. Due to an increase in bloodpressure to 183/89 on Day 24, his Lotensin® dose was increased to 40 mgpo qd and amlodipine besylate (Norvasc®) 5 mg/qd was started. TheNorvasc® dose was increased to 10 mg po qd on Day 32 due a bloodpressure reading of 177/88 mm Hg. On Day 41, hydrochlorothiazide wasadded due to a blood pressure reading of 160/85 mm Hg. The highest bloodpressure reported for subject 1 was on Day 21, 15 minutes post infusion,at 199/92. The subject continued on Lotensin®, Norvasc® andhydrochlorothiazide with adequate blood pressure control and no symptomsrelated to hypertension.

Example 3 Hypertension and Treatment in Subject No. 2

Subject 2, enrolled in the 1.0 mg/kg cohort, is a 55-year-old male withlow-grade leiomyosarcoma. The Table of FIG. 2 is a summary of Subject2's blood pressure readings and anti-hypertensive treatments throughoutthe Phase I study of OMP-21M18. The subject's prior medical historyincluded a diagnosis of hypertension. At study entry, the subject hadbeen taking lisinopril 10 mg po qd for over three years forhypertension. Baseline blood pressure was 141/85 mm On Day 0, thesubject received his first weekly dose of OMP-21M18 at 1 mg/kg. On Day7, the subject's blood pressure increased to a high of 177/93 mm Hg, andthus on Day 13 irbesartsan/hydrochlorothiazide 300/12.5 mg po qd wasadded to the lisinopril. On Day 14, the scheduled dose of study drug wasnot administered due to a hypertensive blood pressure reading of 173/110mm Hg. The regimen of lisinopril 10 mg po qd plusirbesartsan/hydrochlorothiazide 300/12.5 mg po qd did not adequatelycontrol the subject's blood pressure, and thus on Day 17, theirbesartan/hydrochlorothiazide and lisinopril were discontinued andlabetalol 100 mg po bid and Prinzide® 10/12.5 po qd were initiated. OnDay 21, the labetalol was increased to 300 mg q am and 200 mg q pm dueto a blood pressure reading of 164/112 mm Hg. Two days later, thelabatolol dose was increased to 400 mg po bid. This regimen controlledthe subject's blood pressure until Day 55, when a blood pressure readingof 163/91 mm Hg was observed that resulted in increasing the Prinzide®dose to 20/25 po qd. On Day 84, the subject's blood pressure was 167/102mm Hg and lasix 20 mg po qd was added to the regimen. Due to the highblood pressure reading on Day 84, the subjects dose of OMP-21M18 was notadministered. On Day 87, to regain blood pressure control, Norvasc® 10mg po qd was started. The subject's regimen of labetalol 400 po bid,lasix 20 mg po qd, Norvasc® 10 mg po qd, and Prinzide® 20/25 mg po bid,subsequently controlled his blood pressure, allowing him to receive 7additional doses of OMP-21M18 without hypertension.

Example 4 Hypertension and Treatment in Subject No. 3

Subject 3, enrolled in the 2.5 mg/kg cohort, is a 64-year-old woman witha choroidal melanoma of the right eye and metastases in both the liverand the lung. The Table of FIG. 3 is a summary of Subject 3's bloodpressure readings and anti-hypertensive treatments throughout the PhaseI study of OMP-21M18. This subject had no prior history of hypertension.The subject's baseline blood pressure was 96/54 mm Hg. On Day 0, thesubject received her first weekly dose of OMP-21M18 at 2.5 mg/kg. On Day21, the subject had a blood pressure reading of 159/90 mmHg and wasstarted on Dyazide® (hydrochlorothiazide and triamterene) 1 po qd. Thesubject's blood pressure was adequately controlled until Day 112, whenher blood pressure was noted to be elevated to 152/77 mm Hg. To regainblood pressure control, Dyazide® was discontinued and the subject wasbegun on Norvasc® (amlodipine besylate) 5 mg po qd. On Day 141, Norvasc®treatment was discontinued due to ankle edema and lisinopril 20 mg po qdwas begun. On Day 144, the subject's lisinopril dose was increased to 20mg po bid. On Day 146 the subject's blood pressure reading was 143/85 mmHg. The subject has not had symptoms related to the blood pressureincrease. The subject remained on treatment and received 13 infusions ofOMP-21M18.

Example 5 Hypertension and Treatment in Subject No. 4

Subject 4, enrolled in the 2.5 mg/kg cohort, had a history ofhypertension and was taking dyazide and lisinopril at study entry. Thesubject's blood pressure at baseline was 118/73. On Day 14, the subjecthad a blood pressure of 153/79. The increase in blood pressure was notrelated to the study drug according to the Investigator. The subject didnot have symptoms related to the hypertension.

Example 6 Hypertension and Treatment in Subject No. 5

Subject 5, enrolled in the 10 mg/kg cohort, is a 56-year-old female withstage IV colorectal cancer. The Table of FIG. 4 is a summary of Subject5's blood pressure readings and anti-hypertensive treatments throughoutthe Phase I study of OMP-21M18. The subject's past medical historyincludes diagnoses of coronary heart disease, atherosclerosis, andexertional angina (class 1). Subject 5's baseline blood pressure was130/90 mm Hg on Day −28. On Day 0, the subject received her first doseof once every other week OMP-21M18 at 10 mg/kg. On Day 9, the subject'sblood pressure was high, at 160/90 mm Hg, and she was started onlisinopril 10 mg po qd. On Day 14, the subject's blood pressure readingsin the clinic were lower, at 135-140/90 mm Hg, and therefore her dose oflisinopril was reduced to 5 mg po qd. On Day 26, the subject's bloodpressure at home was 170/90 mm Hg and was treated with a single dose ofcaptopril 25 mg po. On Day 28, the subject's dosage of lisinopril wasincreased back to 10 mg po qd. On Day 56, the dose of lisinopril wasincreased to 10 mg po bid due to blood pressure readings of 140-145/90mm Hg. On Day 62, the subject had a blood pressure of 190/120 mm Jig andwas seen by a cardiologist who discontinued the lisinopril and startedher on lozartan 25 mg po qd, bisoprolol 2.5 mg po qd and amlodipine 5 mgpo qd. Three days later, on Day 65, the subject's blood pressure wasstill 170/106 mm Hg. The cardiologist increased the dose of lozartan to50 mg po qd and increased the dose of bisoprolol to 5 mg po qd.

Example 7 Hypertension and Treatment in Subject No. 6

Subject 6, enrolled in the 10 mg/kg cohort, did not have a prior historyof hypertension. The subject's baseline blood pressure was 125/90. OnDay 9, the subject was started on enalapril 10 mg bid. The subsequentblood pressure was 140/90. On Day 28 the subject had a single bloodpressure reading of 150/90. A subsequent blood pressure reading was150/90. The subject did not have symptoms related to hypertension andcontinued to receive treatment.

Example 8 Hypertension and Treatment in Subject No. 7

Subject 7, enrolled in the 10 mg/kg cohort, is a 71-year-old female withstage IV adenocarcinoma of the rectosigmoid junction. The Table of FIG.5 is a summary of Subject 7's blood pressure readings andanti-hypertensive treatments throughout the Phase I study of OMP-21M18.The subject's past medical history includes diagnoses of coronary heartdisease, arterial hypertension, and atherosclerosis. The subject hasbeen taking enalapril 5 mg po bid for hypertension for the past 10years. On Day −1, the subject's baseline blood pressure was 135/90 mmHg. On Day 0, she received her first dose of once every other weekOMP-21M18 at 10 mg/kg. On Day 9, the subject's enalapril dose wasincreased to 10 mg bid when the subject's blood pressure reading was170/90 mm Hg. On Day 56, amlodipine 5 mg po qd was started when thesubject's blood pressure reading was 155/90 mm Hg. The subject's bloodpressure readings on Day 70 were 145-150/90 mm Hg. The subject did nothave symptoms related to hypertension and continued to receivetreatment.

Example 9 Hypertension and Treatment in Subject No. 8

Subject 8, enrolled in the 10 mg/kg cohort, is a 58-year-old man withstage IV colorectal cancer. The Table of FIG. 6 is a summary of Subject8's blood pressure readings and anti-hypertensive treatments throughoutthe Phase I study of OMP-21M18. His past medical history includes adiagnosis hypertension. At the time of study entry, the subject had beentaking captopril 25 mg po qd as needed for the past 6 years to controlhis blood pressure. The subject's baseline blood pressure on Day −28 was140/90 mm Hg. On Day 0, he received his first dose of once every otherweek OMP-21M18 10 mg/kg. On Day 18, the subject's captopril dose waschanged to 12.5 po qd due to a home blood pressure reading of 160/90 mmHg on Day 17. The subject's next blood pressure in the clinic on Day 22was 130/80 mm Hg. On Days 23-28, the subjects blood pressure at homemeasured 150/90 mm Hg and thus the subject's captopril dose wasincreased to 25 mg po qd. Subsequently, the subject received 5additional doses of OMP-21M18 without any further adjustments of hisblood pressure medications. The subject did not had symptoms related tothe reported hypertension and remained on treatment.

Example 10 Hypertension and Treatment in Subject No. 9

Subject 9, enrolled in the 10 mg/kg cohort, is a 54-year-old man withlocally advanced adenocarcinoma of the head of the pancreas. The Tableof FIG. 7 is a summary of Subject 9's blood pressure readings andanti-hypertensive treatments throughout the Phase I study of OMP-21M18.The subject received prior treatment with gemcitabine. The subject didnot have a history of hypertension. The subject's blood pressure on Day−1 was 115/75 mm Hg. On Day 0, he received his first dose of once everyother week OMP-21M18 10 mg/kg. On Day 3, the subject reported anincreased blood pressure of 140-145/90-95 mm Hg and was started onnifedipine 20 mg po qd. The subject's next blood pressure reading on Day7 was 130/80 mm Hg. On Day 74, the nifedipine was discontinued by thesubject due to normalization of his blood pressure (115/75 mm Hg). Thesubject has not had symptoms related to hypertension and remains ontreatment at Day 81.

1. A method of treating cancer comprising: administering to a subject inneed thereof a delta like ligand-4 (DLL4) antagonist and one or moreanti-hypertensive agents, wherein the DLL4 antagonist is an antibodythat specifically binds the amino-terminal region of human DLL4 (SEQ IDNO:11).
 2. The method of claim 1, wherein the subject suffers fromhypertension, is at risk for development of hypertension, or is asubject in which the prevention or inhibition of hypertension isdesirable.
 3. The method of claim 1, wherein the subject is at risk forcardiovascular disease or cannot otherwise be treated with anappropriate dose of the DLL4 antagonist without developing hypertension.4. The method of claim 1, wherein the antibody and the anti-hypertensiveagent are administered separately or simultaneously.
 5. (canceled) 6.The method of claim 1, wherein the antibody is encoded by the plasmidhaving ATCC deposit no. PTA-8425.
 7. The method of claim 1, wherein theantibody competes for specific binding to human DTL4 with an antibodyencoded by the plasmid deposited with ATCC, having deposit no. PTA-8425.8. The method of claim 1, wherein the antibody is selected from thegroup consisting of: monoclonal, humanized, chimeric, human, Fab, Fv andscFv.
 9. The method of claim 1, wherein the antibody comprises: (i) aheavy chain variable region comprising CDR amino acid sequences CDR1(SEQ ID NO:1); CDR2 (SEQ ID NO:2, SEQ ID NO: 3, or SEQ ID NO:4); andCDR3 (SEQ ID NO:5), and (h) a light chain variable region comprising CDRammo acid sequences CDR1 (SEQ ID NO:7); CDR2 (SEQ ID NO:8); and CDR3(SEQ ID NO:9).
 10. The method of claim 9, wherein the heavy chainvariable region comprises CDR ammo acid sequences CDR1 (SEQ ID NO:1),CDR2 (SEQ ID NO:3), and CDR3 (SEQ ID NO:5), and the light chain variableregion comprises CDR amino acid sequences CDR1 (SEQ ID NO:7); CDR2 (SEQID NO:8); and CDR3 (SEQ ID NO:9).
 11. The method of claim 1, wherein theantibody comprises a heavy chain variable region comprising the aminoacids of SEQ ID NO:6.
 12. The method of claim 1, wherein the antibodycomprises a light chain variable region comprising the amino acids ofSEQ ID NO:10.
 13. The method of claim 1, wherein the anti-hypertensiveagent is selected from the group consisting of: a diuretic, anadrenergic receptor antagonist, an adrenergic receptor agonist, acalcium channel blocker, an ACE inhibitor, an angiotensin II receptorantagonist, an aldosterone antagonists, a vasodilator, a renininhibitor, and combinations thereof.
 14. The method of claim 13, whereinthe diuretic is selected from the group consisting of: furosemide,bumetanide, ethacrynic acid, torsemide, epitizide, hydrochlorothiazide,hydroflumethiazide, chlorothiazide, bendroflumethiazide, polythiazide,trichlormethiazide, cyclopenthiazide, methyclothiazide, cyclothiazide,mebutizide, indapamide, chlortalidone, metolazone, quinethazone,clopamide, mefruside, clofenamide, meticrane, xipamide, clorexolone,fenquizone, amiloride, triamterene, eplerenone, benzamil, potassiumcanrenoate, canrenone, spironolactone, mannitol, glucose, urea,conivaptan, relcovaptan, nelivaptan, lixivaptan, mozavaptan, satavaptan,tolvaptan, demeclocycline, mersalyl acid, meralluride, mercaptomerin,mercurophyllme, merethoxyllme procaine, calomel, caffeine, theobromine,paraxanthine, theophylline, acetazolamide, methazolamide, dorzolamide,sulfonamide, topiramate, amanozine, arbutin, chlorazanil, etozolin,hydracarbazine, isosorbide, metochalcone, muzohmme, perhexyline, andticrynafen.
 15. The method of claim 13, wherein the adrenergic receptorantagonist is selected from the group consisting of: atenolol,metoprolol, nadolol, oxprenolol, pindolol, propranolol, timolol,acebutolol, bisoprolol, esmolol, labetalol, carvedilol, bucindolol,nebivolol, alprenolol; amosulalol, arotinolol, befunolol, betaxolol,bevantolot, bopindolol, bucumolol, bufetolol, bufuralol, bumtrolol,bupranolol, butidrine hydrochloride, butofilolol, carazolol, carteolol,celiprolol, cetamolol, cloranololdilevalol, epanolol, indenolol,levobunolol, mepindolol, metipranolol, moprolol, nadoxolol, nipradilol,penbutolol, practolol, pronethalol, sotalol, sulfinalol, talinolol,tertatolol, tilisolol, toliprolol, xibenolol, phenoxybenzamine,prazosin, doxazosin, terazosin, trimazosin, phentolamine, amosulalol,arotinolol, dapiprazole, fenspinde, indoramin, labetalol, naftopidil,nicergolme, tamsulosin, tolazolme, moxonidme, reserpine, and yohimbine.16. The method of claim 13, wherein the adrenergic receptor agonist isselected from the group consisting of: clonidine, methyldopa,guanfacine, methoxamine, methylnorepinephrine, oxymetazoline,phenylephrine, guanabenz, guanoxabenz, guanethidine, xylazine, andtizanidme.
 17. The method of claim 13, wherein the calcium channelblocker is selected from the group consisting of: amlodipine,felodipine, nicardipine, nifedipine, nimodipine, isradipine,nitrendipine, aranidipine, barnidipine, benidipine, cilnidipine,efonidipine, elgodipine, lacidipine, lercanidipine, manidipine,nilvadipine, nisoldipine, diltiazem, verapamil, bepridil, clentiazem,fendiline, gallopamil, mibefradil, prenylamine, semotiadil, terodiline,cinnarizine, flunarizine, lidoflazine, lomerizine, bencyclane,etafenone, and perhexyline.
 18. The method of claim 13, wherein the ACEinhibitor is selected from the group consisting of: captopril,zofenopril, enalapril, ramipril, quinapril, perindopril, lismopril,benazepril, fosinopril, ceronapril, casokinins, lactokinins, teprotide,alacepril, cilazapril, delapril, imidapnl, moexipnl, rentiapril,spirapril, temocapril, moveltipnl and trandolapril.
 19. The method ofclaim 13, wherein the angiotensin II receptor antagonist is selectedfrom the group consisting of: candesartan, eprosartan, irbesartan,losartan, olmesartan, telmisartan, and valsartan.
 20. The method ofclaim 13, wherein the aldosterone antagonists is selected from the groupconsisting of: eplerenone, canrenone, and spironolactone.
 21. The methodof claim 13, wherein the vasodilator is selected from the groupconsisting of: bencyclane, cinnarizine, citicoline, cyclandelate,ciclonicate, diisopropylamine dichloroacetate, eburnamonine, fasudil,fenoxedil, flunarizine, ibudilast, ifenprodil, lomerizine, nafronyl,nicarnetate, nicergoline, nimodipine, papaverine, tinofedrine,vincamine, vinpocetine, viquidil, amotriphene, bendazol, benfurodilhemisuccinate, benziodarone, chloracizme, chromonar, clobenfural,clonitrate, cloricromen, dilazep, dipyridamole, droprenilamine,efloxate, erythrityl tetranitrate, etafenone, fendiline, floredil,ganglefene, hexestrol bis(P-diethylaminoethyl)ether, hexobendine,itramin tosylate, khellin, lidoflazine, mannitol hexanitrate,medibazine, nitroglycerin, pentaerythritol tetranitrate, pentrinitrol,perhexyline, pimethylline, prenylamine, propatyl nitrate, trapidil,tricromyl, tnmetazidine, trolnitrate phosphate, sildenafil, tadalafil,vardenafil, sodium nitroprusside, isosorbide mononitrate, isosorbidedinitrate, pentaerythritol tetranitrate, theobromine, visnadine,aluminium nicotmate, bamethan, bencyclane, betahistine, bradykinin,brovincamine, bufeniode, buflomedil, butalamine, cetiedil, ciclonicate,cinepazide, cinnarizine, cyclandelate, diisopropylamine dichloroacetate,eledoisin, fenoxedil, flunarizine, hepronicate, ifenprodil, iloprost,inositol niacinate, isoxsuprine, kallidin, kallikrein, moxisylyte,nafronyl, nicametate, nicergoline, nicofuranose, nylidrin, pentifyllme,pentoxifylline, piribedil, prostaglandin E1, suloctidil, tolazoline, andxanthinol niacinate.
 22. The method of claim 13, wherein the renininhibitor is selected from the group consisting of: aliskiren andremikiren.
 23. The method of claim 13, further comprising administeringa third therapeutic agent.
 24. A method of ameliorating hypertension ina patient receiving treatment with a DLL4 antagonist, wherein the DLL4antagonist is an antibody that specifically binds the amino-terminalregion of human DLL4 (SEQ ID NO:11), said method comprising:administering to the patient receiving treatment with the antibody, aneffective amount of an anti-hypertensive agent.
 25. The method of claim24, wherein the antibody and the anti-hypertensive agent areadministered separately or simultaneously.
 26. The method of claim 24,wherein the anti-hypertensive agent is selected from the groupconsisting of: a diuretic, an adrenergic receptor antagonist, anadrenergic receptor agonist, a calcium channel blocker, an ACEinhibitor, an angiotensin II receptor antagonist, an aldosteroneantagonists, a vasodilator, a renin inhibitor, and combinations thereof.27. A method of preventing hypertension in a patient receiving treatmentwith a DLL4 antagonist, wherein the DLL4 antagonist is an antibody thatspecifically binds the amino-terminal region of human DLL4 (SEQ IDNO:11), comprising: administering to the patient receiving treatmentwith the antibody an effective amount of an anti-hypertensive agent. 28.The method of claim 27, wherein the anti-hypertensive agent isadministered before, concurrently with, or after the administration ofthe antibody.
 29. The method of claim 27 wherein the anti-hypertensiveagent is selected from the group consisting of: a diuretic, anadrenergic receptor antagonist, an adrenergic receptor agonist, acalcium channel blocker, an ACE inhibitor, an angiotensin II receptorantagonist, an aldosterone antagonists, a vasodilator, a renininhibitor, and combinations thereof.
 30. A method of monitoring apatient receiving treatment with a DLL4 antagonist for the developmentof hypertension, wherein the DLL4 antagonist is an antibody thatspecifically binds the amino-terminal region of human DLL4 (SEQ IDNO:11), comprising: a. measuring the blood pressure of a patientreceiving treatment with the antibody for a blood pressure above thenormal range; b. administering to the patient with the elevated bloodpressure one or more antihypertensive agents. 31-51. (canceled)